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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610472
Report Date: 01/03/2024
Date Signed: 01/04/2024 07:42:27 AM

Document Has Been Signed on 01/04/2024 07:42 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AV RCFE, OLDFIELDFACILITY NUMBER:
197610472
ADMINISTRATOR:DE GUZMAN,FERNANDO JR.FACILITY TYPE:
740
ADDRESS:839 EAST OLDFIELD STREETTELEPHONE:
(805) 551-0062
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 0DATE:
01/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Fernando De Guzman, Jr.TIME COMPLETED:
02:00 PM
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On 01/04/2024, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced pre-licensing visit to this facility and met with the Administrator and the business partner. This is a new application and a fire clearance dated 10/24/2023 was received for five (5) non-ambulatory residents and one (1) bedridden resident. The facility phone number is 661-418-0425..

The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. Component III was conducted with the applicant from 9:15 am until 10:20 am.

Today’s site visit consisted of LPA touring the physical plant inside and outside from 10:35 am until 11:10 am. LPA Spaeth observed the following:

Common Areas – The living room contained comfortable seating. The dining room table and chairs are located in the kitchen. The family room contained comfortable seating and games.

Kitchen - The facility contained a seven-day supply of non-perishable food and a two-day supply of perishable foods. A fire extinguisher is located in the kitchen. Appliances in the kitchen appeared to be functional. The knives and medications were locked in a medication cabinet which is stored on the kitchen counter. The pantry contained emergency food and water.

Backyard - The backyard contained comfortable seating. The side gate leading from the backyard to the front yard was not locked.

Continued - 809C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AV RCFE, OLDFIELD
FACILITY NUMBER: 197610472
VISIT DATE: 01/03/2024
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Bedrooms - There are three (3) bedrooms which contained beds, a mattress on each bed, linens, night stand, lamp, a chair, chest of drawers, and a closet.

Bathrooms- There are two bathrooms which contained hand soap, paper towels, grab bars, slip resistant mats and a trash can. The water temperature was recorded at 11:11 am and was 110. degrees F.

Hallway - The hallway closet was locked and contained cleaning solutions. A hallway cabinet contained linens and personal hygiene items.

Garage- LPA observed the garage was locked and contained the washer and dryer.

The smoke/carbon monoxide detectors were tested at 11:30 am and were operable. The facility was clean and appears to be in good repair. LPA observed the egress delayed alarm was functional.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with Licensee. A copy of this report was signed and delivered.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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